MEDICARE: CLEVELAND STATE UNIVERSITY HEALTH AND WELLNESS SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS1000X	Student Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	36D0874476	OTHER	OH	CLIA
3	02-0251800	OTHER	OH	PHARM LICENSE #

General Provider Information

NPI Number	:	1023090974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEVELAND STATE UNIVERSITY HEALTH AND WELLNESS SERVICES

Provider Business Mailing Address
First Line	:	2121 EUCLID AVE
Second Line	:	UN 263
City	:	CLEVELAND
State	:	OH
Zip	:	44115-2214
Country	:	US
Telephone Number	:	216-687-3649
Fax Number	:	216-687-9319

Provider Business Practice Location Address
First Line	:	2121 EUCLID AVE
Second Line	:	UN 263
City	:	CLEVELAND
State	:	OH
Zip	:	44115-2214
Country	:	US
Telephone Number	:	216-687-3649
Fax Number	:	216-687-9319

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	EILEEN GUTTMAN
Credential	:	CNP
Telephone Number	:	216-687-3649

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	08/17/2018

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Directions to “CLEVELAND STATE UNIVERSITY HEALTH AND WELLNESS SERVICES ” Practice Location

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